Healthcare Provider Details

I. General information

NPI: 1205465895
Provider Name (Legal Business Name): GILLIAN VAUGHAN HEARD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 E 3RD ST
DELTA CO
81416-2815
US

IV. Provider business mailing address

12484 WOODBURY HWY
GREENVILLE GA
30222-3827
US

V. Phone/Fax

Practice location:
  • Phone: 970-874-7681
  • Fax:
Mailing address:
  • Phone: 770-823-3879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0008918
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9715
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: